ADDIS ABABA UNIVERSITY FACULTY OF MEDICINE SCHOOL OF PUBLIC HEALTH

Transcription

1 ADDIS ABABA UNIVERSITY FACULTY OF MEDICINE SCHOOL OF PUBLIC HEALTH ASSESSMENT OF FACTORS AFFECTING HIV VOLUNTARY COUNSELING AND TESTING UPTAKE AMONG BAHIR DAR UNIVERSITY STUDENTS, BAHIR DAR TOWN. By Nebiyu Hiruy(Bsc) Advisor Professor Ahmed Ali A THESIS SUBMITTED TO THE SCHOOL OF GRADUATE STUDIES OF ADDIS ABABA UNIVERSITY IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF PUBLIC HEALTH July, 2008 Addis Ababa, Ethiopia.

2 ACKNOWLEDGEMENT First and foremost I would like to express my deepest gratitude to my advisor Professor Ahmed Ali for his unreserved guidance and encouragement through every step of my research process. I am also grateful to Dr. Nigussie Deyassa and Dr. Alemayehu Worku for kindly sharing their statistical knowledge. My heartfelt thanks goes to the study participants and data collectors for making the research real by participating in the research and their commitment in the process of data collection and data cleaning respectively. I would like to thank the School of Public Health for giving me this opportunity. I am also indebted to EPHA for sponsoring the research financially without which my study couldn t have been accomplished. My special thanks go to my family, especially my dad for being my courage and inspiration to get going on the track. I also extend my thanks to AIDS Resource Center and Science Faculty Digital Library for providing me internet service and HIV/AIDS related documents. Lastly, I sincerely thank Bahir Dar University, Deans of the Faculty, and all departments for allowing me to collect data. May God bless you all. I

3 Table of contents Pages Acknowledgement....I. Table of contents... II List of tables...iii List of figures... IV List of annexes.... V List of abbrevations... VI Abstract... VII 1. Introduction 1.1. Background Statement of the problem Literature review Objective Methodology 4.1. Study area Study population Study design Study variables Sample size Sampling technique Data collection tools and procedure Data quality Operational definition Data entry and processing Data analysis Ethical considerations Result dessimination Results Discussion Strengths and limitations of the study Conclusion Recommendation References Annexes II

4 List of tables Pages Table 1. Demographic characteristics of the study respondents...23 Table 2. Distribution of the respondents by sexual history...24 Table 3 Knowledge of study participants about HIV/AIDS...25 Table 4 Knowledge about VCT along with academic year...29 Table 5 Respondents willingness to undergo VCT and preference of VCT service...35 Table 6 Association of demographic variables with VCT uptake(model 1) Table 7 Association of knowledge, sexual intercourse and stigma/discrimination with VCT uptake(model 2)...39 Table 8 Stepwise logistic regression of variables (model 3) III

5 List of figures Pages Fig 1 Schematic presentation of the sampling method...16 Fig 2 Sources of information of HIV/AIDS for among study respondents Fig 3 Reasons for considering oneself at risk for HIV infection Fig 4 Source of information about VCT among study respondents Fig 5 Response to the question who do you think benefits from HIV testing? Fig 6 Onset of HIV testing of study respondents among those who have been tested...31 Fig 7 Reasons for being satisfied with VCT service among those who had been tested...32 Fig 8 Reasons for not taking VCT among those who had not been tested...33 Fig 9 Willingness to share positive HIV result among study respondents...36 IV

6 List of annexes Pages Annex 1. Conceptual framework of voluntary counseling and testing...56 Annex 2. Structured English questionnaire for quantitative study Addis Ababa University Medical Faculty School of Public Health...57 Annex 3. Structured Amharic questionnaire for quantitative study...68 V

7 LIST OF ACRONYMS AAU - Addis Abeba University ANC Antenatal Care ART - Anti Retroviral Therapy BSS Behavioral Sentinel Survey BDU Bahir Dar University CHWs- Community Health Workers DALY - Disability-Adjusted Life Year DHS - Demographic and Health Survey EPHA - Ethiopian Public Health Association FoM Faculty of Medicine FP Family Planning HCT- HIV Counseling and Testing IEC/BCC Information Education Communication/ Behavioral Change Communication MoH - Ministry of Health OI Opportunistic Infections PLWHA - People Living With HIV/AIDS PLHA Persons Living With AIDS PMTCT Prevention of Mother-To-Child Transmission SPH School of Public Health UNAIDS - United Nations Programme on HIV/AIDS USA- United States of America VS Versus VCT- Voluntary Counseling and Testing WHO- World Health Organization VI

8 ABSTRACT Since the first case of AIDS was recognized in America in 1981, HIV/AIDS has spread rapidly throughout the world. Different studies showed that a great proportion of people living with HIV/AIDS do not know that they carry the virus making VCT service underutilized. However, the reasons for young people for not taking VCT services are not well known. Moreover, University students fall within the most sexually active and high HIV risk group. This study tried to assess the reasons why Bahir Dar University students prefer to or not to take HIV test. This study was conducted from March - April 2008 among Bahir Dar University undergraduate students to assess the factors affecting voluntary counseling and testing uptake. The study design was descriptive cross-sectional. Stratified random sampling was applied to select samples. A standardized questionnaire was used after pre-test to collect quantitative data. Data entry and analysis was done using SPSS. A total of 360 students participated in the study of whom 255 were males. Majority (90.6%) were within the age range of 18 to 23 years. The mean age was 21.26(± sd 1.987). Most of the respondents (95.3%) were single. The study revealed that 38.6% of the study participants had undergone HIV test. Stepwise multivariate analysis showed that being female, second year or above, starting sexual intercourse and knowledge about VCT location were positively associated likelihood of having had HIV testing. Respondents with stigmatizing attitude were less likely to utilize the service. The study shows that stigma still plays a major role as a barrier for utilization of HIV testing services. The University should intensify activities pertaining to curbing stigma and discrimination so that the willingness of students for HIV counseling and testing could be paralleled with actual use of HIV testing. VII

9 1. INTRODUCTION 1.1 Background Currently, Ethiopia is classified as a country with a generalized HIV/AIDS epidemic (1). The first evidence of Human Immuno Deficiency Virus (HIV) in Ethiopia was found in 1984, and the first AIDS case was detected in The HIV/AIDS policy of Ethiopia was formulated by the Ministry of Health (MOH) and adopted by the Council of Ministers in 1998 (2). This created an enabling environment for HIV/AIDS prevention and control. The priority interventions in the policy and being implemented by the country include: Information Education Communication/ Behavioral Change Communication (IEC/BCC), Voluntary Counseling and Testing (VCT) and others. From these, VCT which is the focus of this research is the entry point to other activities. According to Demographic Health Survey(DHS 2005), among the adult population aged in Ethiopia, 4 percent of women and 6 percent of men have been tested for HIV at some time in their life, which is very low (3). Thus, it is important to examine factors that motivate, or deter, individuals from seeking HIV testing. These determinant factors are expected to differ from sub population to sub population. The identification of the factors affecting the uptake of VCT has an impact on prevention and control of HIV/AIDS. Eventhough studies relating to willingness and utilization of VCT are done among pregnant women, adult population, and others, little was done targeting university students in the Ethiopian setting. University students are among the most HIV exposed groups due to their age and style of living. This study was performed to assess factors affecting VCT uptake among Bahir Dar University students. This information could serve as basis for policy formulation on the current VCT uptake.

10 1.2. Statement of the problem Less than 1% of adults aged years are accessing VCT services in the 73 low- and middleincome countries most affected by AIDS(4). The proportion is highest in countries worst affected by the epidemic. VCT is vastly underutilized, particularly in poor countries, where the current overall coverage is estimated to be less than 1% to 10% of those at risk for HIV (5). In a population-based survey in Tanzania, 7% of women and 12% of men reported ever having received an HIV test (6). According to BSS round two report in Ethiopia, only 9.3% and 13% of in school youths and out of school youths had undergone HIV test respectively (7). Even though there are no local studies done on undergraduate students in relation to VCT uptake, DHS 2005 Ethiopia indicated that the proportion who tested and received results for VCT in the age group years was 6.7% which is very low (3). Millennium AIDS campaign in Ethiopia (MAC-E) phase II which was conducted from February to August 2007 had 53% achievement on HIV counseling and testing (HCT) (8). Additionally, Amhara Region had an achievement of 51% of the planned which is not an acceptable performance. The expansion of access to Anti Retroviral Therapy (ART) and Opportunistic Infections (OI) management will not succeed unless the role played by counseling and testing as a gateway to effective treatment is intensified by reaching many people. 2

11 2. LITERATURE REVIEW 2.1. Global and Ethiopian magnitude of HIV/AIDS Since the first case of AIDS was recognized in America in 1981, HIV/AIDS has spread rapidly throughout the world. Joint UNAIDS and WHO statistics in December 2007 show that the number of people living with HIV totaled 33.2 million. An estimated 2.5 million were newly infected with HIV and an estimated 2.1 million lost their lives to AIDS. Although these estimates are lower than those published in the AIDS epidemic update- 2006, the number of people living with HIV is still huge (9). Sixty eight percent of all persons infected with HIV are living in Sub-Saharan Africa 22.5 million. In this region, an estimated 1.7 million adults and children became infected with HIV in 2007, more than in all other regions of the world combined. The 1.6 million AIDS deaths in Sub- Saharan Africa represent 76% of global AIDS deaths (9). The total number of people living with HIV/AIDS (PLWHA), according to the latest single point estimate for HIV/AIDS 2007 in Ethiopia is close to one million (977,394) making HIV prevalence of 2.1% i.e. 7.7% for urban and 0.9% for rural (10). The number of new infections and AIDS deaths for 2007 is 125,528(about 344 per day) and 71,902 respectively. Amhara Region with HIV prevalence of 2.7% has a total of 318,291 PLWHA in the year 2007 which is more than 30 % of the load of the country. In the Region, the prevalence of HIV among urban population is 9.9%. Regarding Bahir Dar Town, according to the sixth MOH AIDS report of 2006, Antenatal (ANC)-based HIV Sentinel Surveillance results for 2002, 2003 and 2005 show the prevalence of HIV/AIDS to be 20.5%, 19% and 13.3% respectively (11). 3

12 2.2. Definition of VCT HIV counseling has been defined as a confidential dialogue between a person and a care provider aimed at enabling the person to cope with the stress and make personal decisions related to HIV/AIDS. VCT is the process by which an individual undergoes counseling to enable him/her to make an informed choice about being tested for HIV. This decision must be entirely the choice of the individual and he or she must be assured that the process will be confidential (12). VCT is not only a key component of both HIV prevention and care programmes, but is the gateway to both prevention and care. In order to respond effectively to options for each, it is preferable for one to know one s serostatus. The development of increasing numbers of effective and accessible medical and supportive interventions for PLWHA means that VCT services are being more widely promoted and instituted(13). There are three types of HIV testing in Ethiopia i.e. Client-initiated or voluntary counseling and testing, provider-initiated testing and counseling and mandatory HIV screening. There are different models that are used by VCT services [14]: I. Freestanding: Facilities set up solely to provide VCT service. II. VCT services integrated with other health services (such as outpatient clinics, FP etc). III. VCT services provided within already established non- health institution and facilities (like youth club, youth or communities centers, church halls, schools etc). VI. Mobile: Out reach VCT services. 4

13 2.3. Uses of VCT VCT alleviates anxiety, increases clients perception of their vulnerability to HIV, promotes behavior change, facilitates early referral for care and support and assists in reducing stigma in the community (15). Moreover, knowledge of HIV status helps HIV negative individuals make specific decisions to reduce risk so that they can remain disease free. For those who are HIV infected, knowledge of their status allows them to take action to protect their sexual partners, to access treatment, and to plan for the future. Testing of pregnant women is especially important so that action can be taken to consider Prevention of mother-to-child transmission (PMTCT) (3). In Sub-Saharan Africa, VCT is a cost-effective method of reducing high-risk sexual behavior and preventing HIV transmission. A large multicenter study conducted in Kenya, Trinidad, and Tanzania demonstrated that VCT reduced unprotected sexual contact with a non primary partner by 35% among men and 39% among women (16). It has been estimated that VCT offered to Tanzanians would avert 895 HIV infections at a cost of $346 per infection averted and $17.78 per DALY saved (17). Because pretest and posttest counseling are offered to individuals who test either HIV positive or HIV negative, there is an opportunity for individualized intervention to discuss risky and safer behaviors and ways to modify risky behavior patterns thereby curbing the spread of HIV infection (18). Most studies involving couples in Africa show that knowledge of HIV test results promotes behavior change and reduces transmission (19).With the expansion of access to ART and OI management, the role counseling and testing as a gateway to effective treatment has grown dramatically. 5

14 2.4. Determinants of VCT uptake The failure to use HIV testing services by significant numbers of individuals at risk for HIV can be attributed to a number of factors, both on individual as well as societal level. For example, among high-risk individuals in the United States of America (USA), reasons given for failing to be tested include fear of learning that they are HIV-positive (25%); belief that they are unlikely to have been exposed to HIV (18%), and belief that they are HIV-negative (13%). Other barriers to HIV testing include perceived stigma and fear of discrimination if sero-positive, concerns over privacy and the issue of who has access to information about one's HIV status (20). According to a study done among Canadians to assess factors associated with HIV testing, results indicated that those at risk are more likely to be tested (21). Another study done in Massachusetts revealed that teens who have had multiple sexual partners and who do not believe condoms are effective in preventing transmission were most likely to have been tested (22). Among sexually active American adolescents it was found that 35% did not believe or did not know that the HIV test results were kept in confidentially [23]. A study done among youth in Hong Kong indicated that factors independently associated with voluntary HIV testing were age and having had sex with multiple partners (24). According to a research done in Jamaica, less than half of students (41.8%) reported having been previously tested for HIV (25). In addition to fear, students in the that study reported not having an HIV test since they believed that they were not at risk of contracting HIV nor infected with the virus. However, HIV testing was not associated with condom use or number of sex partners. 6

15 Another study done in London showed that HIV testing was significantly associated with age and previous sexually transmitted infection diagnosis among women; and additionally, nationality, education, employment, and self perceived risk of acquiring HIV among men (26). According to a research done among youth aged years in Malawi, young people go to VCT mainly to know their HIV status and the availability of VCT services. The provision of VCT services by peers motivate young people to access VCT and some people do not access VCT services due to fears of being HIV positive and poor attitudes towards the health service providers (27). In a study done among University students in India, the US and South Africa, the main reasons for not having been tested for HIV were low perceived susceptibility and fear of being HIV positive (28). Another study done in Northern Nigeria to examine the predictors of readiness for HIV testing among young people found that knowledge about HIV prevention, knowledge about a source for VCT and perceived risk are strong predictors (29). Another study done in Botswana among students from secondary schools and tertiary institutions showed that willingness to test for HIV infection was negatively associated with being sexually active and having a number of partners (30). Another study conducted in Ugandan urban youth discovered that 81% had ever heard about VCT, with health talks as main source of information (51%). Only 28% had ever taken the HIV test; of whom 68% felt pre test counseling had been adequate (31). 7

16 According to a study done among rural Zimbabwean cohort, motivation for VCT uptake was driven by knowledge and education rather than sexual risk (32).A similar study done among Ugandan men indicated that knowledge about AIDS, a history of paying for sex, spousal communication about HIV prevention, secondary or higher education, and neighborhood knowledge of a test site were associated with an increased likelihood of HIV testing (33).A study done among Zimbabwean adults indicated that self-perceived risk and high-risk behavior were positively associated with initial willingness but not with actual use (34). A study done among Kamuzu College of nursing students in Malawi showed that fear of stigmatization, discrimination and disclosure of one s sero status were the main barriers for students access to VCT services. Additionally, it indicated that prevention of getting infected and infecting others were the greatest benefits of knowing one s HIV status (35). Another study done among different community and professional groups in South Gonder Administrative Zone, Ethiopia, found that 92.3%, 96.1% and 56% of BSC nurse students, teacher s training students and hospital health staffs, respectively, were willing to accept VCT (36). In the same study, availability of ART and absence of community support was found to be positively and negatively associated with acceptance of VCT, respectively. Another study in Gonder, North Ethiopia also revealed that those who had self-perceived risk and knowledge of HIV/AIDS prevention methods were more likely to accept VCT than their counterparts (37). A community based study in North West Ethiopia showed that 89.8% of respondents were aware that one could check his /her HIV status, and 73.8% knew about the availability of the service and the majority, 98.2 % stated that VCT is necessary (38). 8

17 Behavioral survey in Assosa revealed that 28.2% of the respondents among adult general population stated that they knew VCT services were available in Assosa, however, only 3.9% ever had an HIV test. Females and individuals who had a positive attitude to take VCT felt that they were at risk of infection (39). According to BSS 2005 only 9.3% of in school youth had undergone an HIV test. Experience of having had an HIV test was statistically significantly different between males and females on bivariate analysis in favor of females (7). A study done in North Wollo Zone among years of age showed that being in age group 20-29, married, educational level of secondary and above, sexual experience with multiple partners, perceived risk for HIV infection, and those who had knowledge about HIV/AIDS and VCT were more likely to utilize service(40). This study also revealed that individuals with discriminating and stigmatizing attitude, and age group were less likely to utilize service. Another study conducted in Jijiga, Ethiopia among youth revealed that being female, older youth, educational level of secondary and above grade and sexually active youth were more likely to be tested (41). This study also reported that the main reason for VCT utilization was to know self (61.6%) and have not had HIV test yet because they are afraid to get the result. 9

18 2.5. University students and behavior towards HIV and VCT University students fall within the most sexually active and high HIV risk group (42). This review of studies on sexual behavior of students in Sub-Saharan Africa indicates high prevalence rates of sexual intercourse and infrequent use of condoms with significant proportions of adolescents having two or more lifetime sexual partners. Majority of undergraduates are in their late teens and early twenties. Most of them live away from home in school hostels. These arrangements weaken parental control and supervision of students' activities. They are often exposed to influences that encourage casual sexual relationships (43). University campuses constitute a potentially fertile breeding ground for HIV/AIDS (44). They bring together in close physical proximity, devoid of systematic supervision a large number of young adults at their peak years of sexual activity and experimentation. Combined with the ready availability of alcohol, together with divergent levels of economic resources, these circumstances create a very high risk environment from an AIDS perspective. Factors such as peer pressure, lack of maturity, and alcohol and drug use put college students at risk for HIV infection (45). Additionally, according to a paper concerning universities in South and Western Africa, the prevailing "culture" of university campuses the unspoken assumption that "this is the way things happen here, these patterns of behavior are acceptable in our circumstances" appears to be ambivalent about, or even open to, sugar daddy practices, sexual experimentation, prostitution on campus, unprotected casual sex, gender violence, multiple partners, and similar high-risk activities (46). 10

19 According to a study done among University students in India, the US and South Africa, one fifth of the American and South African participants, but only 10% of the Indian students admitted having had an HIV test (28). A similar study done among undergraduates in a polytechnic in southeast Nigeria revealed that 26.4% of students had taken an HIV test at one time or another before the study (47) This study was directed at identifying factors affecting VCT uptake among university students. In doing so, the study has established the prevalence of uptake of VCT among the students. The information generated by the research is expected to be useful for the formulation and implementation of HIV prevention activities, especially VCT at campus setting and for the wider youth. 11

20 2.6. Stigma and discrimination Discrimination refers to any form of distinction, restriction, or exclusion a person may encounter because of an inherent personal characteristic (48). Stigma creates, and is reinforced by social inequality. It has its origins deep within the structure of society as a whole and in the norms and values that govern everyday life. It causes some groups to be devalued and ashamed and others to feel that they are superior (49). AIDS-related stigma and discrimination have serious individual and public health ramifications that contribute to a reluctance to be tested for HIV and to disclose positive test results to partners, poor treatment adherence, and increased risk of disability and drug resistance (50). One study found that utilization of VCT services is positively associated with lower levels of HIV/AIDS stigma (51). Another study indicated that compared to people who had been tested, individuals who were not tested for HIV demonstrated significantly greater AIDS related stigmas; ascribing greater shame, guilt, and social disapproval to people living with HIV(52). Students tend to associate strong stigma with HIV/AIDS. Even where there may be no overt discrimination against them, HIV-positive individuals may experience subtle forms of prejudice. As a result, it is difficult for those who are willing to do so to come out publicly about their HIV status. This has contributed to the absence of clearly identified PLWHA groups on university campuses (46). An investigation at the University of Botswana found significant negative attitudes toward the disease and towards those affected: "There were fears expressed regarding eating and working with infected students (53). (Conceptual framework is attached) 12

21 2. OBJECTIVE 2.1 General objective To assess the factors affecting voluntary counseling and testing uptake among undergraduate Bahir Dar University students. 2.2 Specific objectives 1. Assess knowledge and attitude of students towards VCT and HIV/AIDS. 2. Explore the prevalence of HIV testing. 3. Assess Willingness of students for utilizing VCT service. 4. Identify demographic and other factors associated with VCT uptake. 13

22 4. METHODOLOGY 4.1. Study area The study area, Bahir Dar University, is found in Bahir Dar Town. Bahir Dar Town which is the capital of Amhara Regional State is located in Northwest Ethiopia about 563 kilometers from Addis Ababa. It has an estimated population of 160,603 of whom 75,901 are males and 84,702 females (54). The Town is subdivided into 17 Kebeles. In the Town, there is one government hospital, 3 health centers, one health station and one Regional Research Laboratory (55). Bahir Dar University is one of the 21 public universities in Ethiopia (56). The University was inaugurated on May 6, 2000 after the two fraternal institutions of higher learning namely, Bahir Dar Polytechnic Institute and Bahir Dar Teachers College were merged. The University has a total of 11,821 undergraduate students. There are four faculties i.e. Education, Business & Economics, Law and Technology faculties Study population All undergraduate students for the academic year 2007/2008 in Bahir Dar University were taken as study population. Students who were in the extension and post graduate programs were not included in the study. Those students who were unable to see were excluded from the study since the questionnaire was self administered Study design: A cross-sectional study was conducted from March - April The study applied quantitative methods. 14

23 4.4. Study variables Some of the variables used were the following:- Dependent variable: HIV testing status Independent variables: 4.5. Sample size Socio-demographic variables: age, sex, religion, ethnicity, academic year and marital status. Knowledge and Attitude about HIV/AIDS and HIV counseling and testing Stigma and discrimination Sexual behavior The sample size was determined considering an outcome estimate of HIV testing uptake. According to the HIV/AIDS behavioral surveillance survey of 2005 Ethiopia, 9.3% of in school youths had undergone an HIV test (7). This group was taken with the assumption that it is close to and representative of the group of undergraduate students. Using 3 % margin of error and 95% confidence interval of certainty (alpha =0.05) as assumption, the actual sample size for the study was computed using one- sample population proportion formula as indicated below. Population correction was not used since the study population was more than 10, n = z α P(1-P) 2 Where, n = Sample size, z α = Critical value =1.96 d 2 P = proportion of being tested = 0.093, 1-P = proportion of not being tested = 0.907, d (marginal error) = 0.03 n = (1.96) 2 (0.093 x 0.907) = (0.03) Adding 5% non-response rate, Total sample size=360+18= 378 respondents. 15

24 4.6. Sampling technique To come up with the respondents, stratified simple random sampling was used. Enumerated list of all the regular students was secured from the registrar of the University in each of the academic years and used as sampling frame. Then proportional allocation was carried out for each of the academic years i.e. year 1, 2 and 3. Simple random sampling using lottery method was used to draw samples from each of the respective academic years. Fig 1 Schematic presentation of the sampling method Total number of undergraduates=11,821 Total number of sample size=378 PROPORTIONAL ALLOCATION FOR THE STRATAS Total no of 1 st yr=4321 Total no of 2 nd yr=3778 Total no 3 rd yr=3722 SIMPLE RANDOM SAMPLING Sampled=138 Sampled=121 Sampled=119 16

25 4.7. Data collection tools and procedure A191-item self administered questionnaire adapted from the BSS and other relevant literatures measuring a variety of demographic factors, HIV-related knowledge, attitudinal and behavioral items was used. Almost all of the questions in the questionnaire were close-ended. The questionnaire was anonymous and this helped to reduce embarrassment and the potential bias of the respondents giving socially acceptable answers. Data collectors and supervisors were recruited and trained. The English version of the questionnaire was translated into Amharic for easy understanding by the respondents. Prior to the main fieldwork, a pilot test (pre-test) was conducted using twenty-five students from the University. The students who were involved in the pretest were excluded from the main study and were characteristically similar to the respondents. The test was used for identifying any problems and omissions as well as to check time spent in responding thereby improving the precision and reliability. Following the analysis of the pilot study data, ambiguous or unclear questions were either rephrased or removed. Three hundred seventy eight questionnaires were administered to the students after explaining the nature and anonymity of the survey, and assuring confidentiality of the personal responses Data quality To ensure data quality consistency was checked by translating the Amharic version back to English. Data were checked for completeness daily by the investigator and incompletely filled questionnaires were returned to the respondents so that they fill it in full. Additionally, a pretesting was conducted to maximize the quality of data. Training was also given to the data collectors which enabled them to help the respondents fill the questionnaire without ambiguity in consistent way. 17

26 4.9. Operational and concept definition of terms Anonymous HIV Testing: Clients identifying information is not linked to testing information. Counseling: Confidential dialogue between a client and care provider aimed at enabling the client to cope with stress and make personal decision related to HIV/AIDS. Confidential HIV Testing: Client s identifying information is linked to testing information of the client. Comprehensive knowledge about HIV/AIDS: Respondents were considered to have comprehensive knowledge about HIV/AIDS if they were both knowledgeable about the three HIV/AIDS prevention methods and had no incorrect beliefs about HIV transmission Knowledge about HIV prevention: Respondents were considered to be knowledgeable about HIV prevention if they correctly identified the three main ways to prevent HIV transmission: abstinence, being faithful to one uninfected partner and condom use. Misconception about HIV/AIDS: Respondents are considered to have misconceptions about HIV/AIDS transmission and prevention if they agreed incorrectly to any of the following three statements about HIV/AIDS: a mosquito bite can transmit HIV, sharing a meal with someone who is HIV positive can transmit HIV, HIV can be transmitted by breathing. Knowledge about VCT: Those who score greater than the mean score of 18 are considered to be knowledgeable about VCT and those who score less than the mean score are taken as not knowledgeable. Knowledge about the location of VCT: Those who mentioned all the four locations of VCT are taken as knowledgeable about VCT location. The choices include can we get VCT service in hospitals? Can we get VCT service in health centers? Can we get VCT service in FGAE? Can we get VCT service in private clinics? 18

27 Discrimination: An action based on stigma and directed towards the stigma filed. HIV tested: Any body who had undergone HIV test regardless of the duration Married: Currently in union. Media: Radio/Television Risk perception of HIV/AIDS: Attitude towards perceiving themselves as susceptible to HIV infection. Stigma: negative feeling towards people with HIV/AIDS, intention to avoid people living with HIV/AIDS from social relationship. Stigmatizing Attitude: The number of indicators are six, namely, not willing to share meal with a person infected with HIV, not willing to give care to a female relative patient, not willing to give care to a male relative patient, not willing to buy food from an HIV infected food seller/shop keep, want to keep secret the sero-status of an HIV infected household member, If a student has HIV, but is not sick, should he or she be allowed to continue attending school? Those respondents with mean score and above related to questions on HIV related stigma are considered as having stigmatizing attitude and those who score less than mean are considered as not having stigmatizing attitude. VCT: A process by which an individual undergoes counseling to enable him/her make informed choice about being tested voluntarily for HIV. Willingness: readiness to undergo to VCT. 19

28 4.10. Data Entry and Processing The questionnaires were checked for completeness and consistency by the principal investigator. The questionnaires were classified as unfilled, partially incomplete, item missed and complete. Totally unfilled and partially filled formats were excluded from the analysis. Fully completed questionnaires were coded and entered. The investigator with the data clerk entered the coded questionnaire into Statistical Package for Social Sciences (SPSS) Version 13.0 program. Few inconsistencies were corrected during data entry. About 72(20%) of the questionnaire were double entered to verify accuracy of data entry and no discrepancies were noted. Data clean up was performed by running frequencies of each variable and sorting to check for accuracy, outliers, and consistencies and missed values Data analysis SPSS was used for data analysis. Univariate and bivariate statistical analyses were employed. During the analysis, frequencies of different variables were determined, and chi square test performed on some selected variables. Odds ratios were calculated to determine the strength of associations of selected variables. Scoring system was used to assess knowledge of respondents about HIV/AIDS, VCT and stigma and discrimination. Every correct answer was given one point while a wrong answer and "Don't Know" were given zero point. Descriptive statistics were used to summarize data. Multiple regressions were also used to explain predictors of current practices. Logistic regression analysis was also made to check whether the results of descriptive summaries and multiple regressions were consistently predicting specific variables. The results were illustrated in the form of frequency tables and depicted graphically in order to give a quick glance of the variables. 20

29 4.12. Ethical considerations Before the study began, ethical clearance was obtained from the IRB of the School of Public Health of Addis Ababa University. Institutional consent was also obtained from the Bahir Dar University after communicating with formal letters from the SPH, AAU. Informed consent was obtained from respondents before they filled questionnaires. Specifically, respondents were informed about the objectives of the study and that their participation was purely voluntary and they were free to decline or withdraw at any time in the course of the study. So only those were willing were included in the study. They were also assured that the information provided whether orally or in writing would be used only for research purpose and would therefore be strictly anonymous and dealt with confidentially Result dissemination Presentation of the finding will be undertaken at SPH, AAU. Then the thesis report will be submitted to SPH, Bahir Dar University and EPHA and publication in peer reviewed national and international journals will be attempted. 21

30 5. RESULTS 5.1. Demographic characteristics of the respondents A total of 378 self-administered questionnaires were distributed for 378 undergraduate students. Eighteen students did not return the completed questionnaire and were excluded from analysis resulting in a response rate of 95%. Two hundred fifty five out of 360 respondents (70.8%) were males, while 105 out of 360 respondents (29.2%) were females. Of the total respondents, 163(45.3%), 163(45.3%) and 34(9.4%) were within the age group of 18-20, and >24 years respectively. The mean age of the study respondents was 21.26(± sd 1.987); 21.39(± sd 2.12) years for males and 21.94(± sd 1.586) years for females. Most of the respondents (95.3%) were singles (Table1). Regarding the academic year of respondents, 135(37.5%), 117(32.5%) and 108(30%) were from first, second and third batches, respectively. Most of the respondents were Amhara by ethnicity (58.9%), followed by Tigre (19.7%), Oromo (13.1%) and others (8.3%). Almost three quarter (72.5%) of the respondents were Orthodox Christians. Muslims, Protestants and other religion followers were 14.2%, 11.7% and 1.7% respectively (Table1). Regarding the educational status of the father of the respondents,82.8 %, 7.2 % and 10 % of the fathers were 8th grade or below, 9 th - 12 th, and above 12 th grade respectively. On the mother side, 93.1 %, 3.3 % and 3.6 % of the mothers of respondents were 8th grade or below, 9 th - 12 th, and above 12 th grade respectively (Table 1). 22

31 Table1. Demographic characteristics of the study participants, BDU, Mar (n=360) Variable Frequency (n) Percentage (%) Sex Male Female Total Age > Total Academic year First Second Third Total Ethnicity Amhara Tigre Oromo Others Total Religion Orthodox Islam Protestant Others Total Marital status Single Married Divorced Total Educational status of father Only able to read and write Unable to read and write > Total Educational status of mother Unable to read and write Only able to read and write > Total

32 5.2. Sexual history of the study subjects One hundred forty two (39.4 %) of the respondents, 118 (46.3%) males and 24(22.9%) females reported to have ever had sexual intercourse (Table 2). Comparatively, males are 2.9 times more likely to be sexually active than females (χ² = 16.1, P=0.000, CI=1.732, 4.879). Sexual activity increases with academic year, being at its lowest for first year students and at its highest for final year students (OR=1.872, P=0.017, CI=1.116, 3.141) (Table 2). Of those who had sexual experience, 77 (54.2%) reported that they had more than one sexual partner. One hundred six (74.6%) of those who had more than one sexual partner reported that they had used condom. Of those who had used condom, 63 (59.4 %) reported that they had used condom always, while 43(40.6%) had used condom sometimes (Table 2). Table2. Distribution of the respondents by sexual history, BDU, Mar Items Sex of the students Male Female Ever had sex (n=360) Yes 118(46.3%) 24(22.9%) No 137(53.7%) 81(77.1%) Ever had sex with multiple sexual partners (n=142) Yes 69(58.47%) 8(33.33%) No 49(41.53%) 16(66.67%) Ever used condom (n=142) Yes 94(79.66%) 12(50%) No 24(20.34%) 12(50%) Frequency of using condom (n=106) Always 56(59.57%) 7(58.33%) Sometimes 38(40.43%) 5(41.67%) 24

33 5.3. Sources of Information on HIV/AIDS and Knowledge about HIV/AIDS All of the respondents have heard of HIV/AIDS. Three hundred eleven (86.4%) of the respondents were knowledgeable about the 4 ways of transmission of HIV/AIDS( unsafe sex, from mother to children, sharing contaminated sharp instrument and infected blood transfusion while 49(13.6%) are less knowledgeable. Regarding the knowledge of respondents about the three ways of prevention of HIV/AIDS (abstinence from sex, faithfulness to partner and using condom) 315 (87.5%) were knowledgeable. Majority of the respondents 343(95.3%) did not report misconceptions about HIV/AIDS (a mosquito bite can transmit HIV, sharing a meal with someone who is HIV positive can transmit the infection, HIV can be transmitted by breathing). Additionally, two hundred ninety nine (83%) of the respondents had comprehensive knowledge about HIV/AIDS (Table3). Table 3 Knowledge of study participants about HIV/AIDS, BDU, Mar. 2008(n=360) Items Frequency Percent % Knowledge about HIV transmission Knowledgeable Not knowledgeable Knowledge about HIV prevention Knowledgeable Not knowledgeable Misconception about HIV/AIDS Present Absent Comprehensive knowledge about HIV/AIDS Knowledgeable Not knowledgeable

34 Regarding sources of information on HIV/AIDS, most of the respondents 344(95.6 %) mentioned mass media as a source of HIV/AIDS related information followed by schools 302(83.9 %) and health institution 272(75.6 %), (Figure 2). mass media 95.6% schools 83.9% health institution 75.6% pamphlets 74.2% religious leaders 61.7% friends 58.1% chws 57.5% family 40.3% 0% 20% 40% 60% 80% 100% 120% Fig 2 Sources of information for HIV/AIDS, BDU, Mar * result of multiple answer question 26

35 5.4. Personal perception of risk of HIV infection. One hundred fifty seven (43.6%) of the respondents consider themselves as being at risk of HIV/AIDS infection for a variety of reasons and 203(56.4%) of the respondents didn t perceive themselves to be at risk of HIV/AIDS infection. Of those who perceived risk, 93(59.2%), 81(51.6%), 79(50.30%), 30(19.1%) and 10(6.8%) mentioned contaminated sharp object injury, having multiple sexual partners, making sexual intercourse without condom, sexual intercourse with prostitute and contaminated blood transfusion as their reasons for being at risk, respectively(figure 3). contaminated sharp object injury, 59.2% contaminated blood transfusion, 6.8% sexual intercourse with prostitute, 19.1% having multiple sexual partner, 51.6% sexual intercourse without condom, 50.3% Fig 3 Reasons for considering oneself at risk for HIV, BDU, Dec.2007 * result of multiple answer question Among those respondents who perceived being at no risk of HIV/AIDS infection, reasons including never having sex, abstaining from sex, being under one-to-one faithful relationship, not sharing sharp materials and using condom were mentioned by 169(8.25%), 150(73.9%), 32(15.7%), 142(69.9%) and 18(8.9%) of the respondents, respectively. 27

36 5.5. Source of information for VCT and knowledge about VCT All of the respondents (100%) have heard of VCT. The most common source of information was mass media 322 (89.4%) followed by health institution 305(84.4%), teacher 160(44.4%), friends 129(35.8%), family 85(23.6%) and others (16.7%) in descending order (Figure 4). 100% 90% 80% 70% 60% 89.4% 84.4% 50% 44.0% 40% 35.8% 30% 20% 10% 23.6% 16.7% 0% mass media health institution teacher friends family others Fig 4 Sources of information for VCT, BDU, Mar * result of multiple answer question 28

37 Two hundred forty five (68.1%) respondents were knowledgeable about VCT answering at least 19 of the 21 score questions (those who score greater than the mean score of 18 were considered to be knowledgeable about VCT) (Table 4). Table 4 Knowledge about VCT along with academic year, BDU, Mar Academic year Knowledge about VCT Not knowledgeable Knowledgeable Total First 69(51.1%) 66(48.9%) 135(100%) Second 25(21.4%) 92(78.6%) 117(100%) Third 21(19.4%) 87(80.6%) 108(100%) Total 115(31.9%) 245(68.1%) 360(100%) 29

38 5.6. Perception on benefits of VCT Nearly all of the respondents (99.2%) stated that counseling is important in undertaking VCT. Three hundred seven respondents(85%), 21(5.8%) and 28(7.8%) claimed both HIV positive and negative persons, HIV negative persons and HIV positive persons respectively would benefit from VCT(Figure 5). HIV negative person, 5.80% HIV positive persons, 7.80% I don't know, 1.10% HIV positive and negative persons, 85% Fig 5 Response to the question who do you think benefits from HIV testing? BDU, Mar With regard to perceived benefits of VCT, 356(98.9%) said it is important to know one s HIV status followed by to take self care, to avoid transmission of HIV/AIDS, to prevent mother-tochild transmission of HIV/AIDS, to plan for future life, to start ART and to choose one s partner in order of 342(95%), 341(94.7%), 309(85.8%), 300(83.3%), 283(78.6%) and 259(71.9%), respectively. 30

39 5.7. Practice of VCT One hundred thirty nine (38.6%) of respondents had undergone an HIV test. The proportion of females tested was 47.6 % while it was 34.9 % for males. Majority of those who had HIV test (96.4%) had undergone the HIV test on voluntary basis. Almost all voluntarily tested respondents (99.2%) took the test for the purpose of knowing their HIV status. Experience of having had an HIV test was statistically significantly different between males and females on bivariate analysis. Amongst those who had been tested, 96.4% were tested on a voluntary basis. The majority (70%) had their most recent HIV test within the previous year, 13.7%-before 1-2 years, 6.4%-before 3 years and 10%-before unknown duration (Figure 6). 3 years ago, 6.3% 1-2 years ago, 13.7% before unknown duration., 10.0% within the previous year, 70.0% Fig 6 Onset of HIV testing among those who have been tested for HIV, BDU, Mar Most of those who were tested (82%) took the test in a health center. Almost all of those who were tested (99.3%) had been given counseling service. Most of those who have been tested (71.7%) stated that they were provided with counseling both before and after testing, while 22.5% and 5.7% were given only pretest or post test counseling, respectively. 31

40 5.8. Satisfaction with the VCT service One hundred twenty seven of those who have ever had VCT (91.4%) stated that they were satisfied with the HIV counseling and testing service they had been offered. The main mentioned reasons for being satisfied included clear counseling 97(76.4%), warm reception 97(76.4%) and free service 80(63%)(Figure 7). clear counseling warm reception free service timely and fast reception confidentiality competence of the health professionals 76.4% 76.4% 63.0% 52.8% 48.0% 34.6% referral service 18.1% 0% 20% 40% 60% 80% 100% Fig 7 Reasons for being satisfied with VCT service among those who had been satisfied for HIV, BDU, March * result of multiple answer question Reasons for not being satisfied reported by those who have not tested include long waiting time(50%),lack of warm reception(41.7%), lack of separate room (41.7%), incompetence of health professionals (33.3%), unclear counseling(25%) and lack of confidentiality(20%). 32

41 5.9. Reasons for not taking HIV test and Respondents counselor choice by profession The most common reason for not taking VCT stated by respondents were perceived less/no risk(51%) followed by fear of stigma(34.4%), trusting oneself or partner(21.7%), and unavailability of the service nearby(3%)(figure 8). 60% 50% 52.0% 40% 34.4% 30% 20% 21.7% 10% 3.0% 0% less/no personal risk perception fear of stigma trusting myself or my friend unavailability of the service nearby Fig 8 Reasons for not taking HIV testing among those who have been tested for HIV, BDU, Mar * result of multiple answer question Regarding preference of counselors, 299 (83%) preferred General Practitioner (GP) followed by trained counselor (66%), HIV positive people (46%) and religious leaders (45%). 33

42 5.10. Willingness to VCT and Preference of VCT methods As Table 5 illustrates, three hundred thirty six of the respondents (93.3%) reported willingness to be tested. Of those who were willing, the majority 233 (69.34%) liked to be tested in government health institutions, 41(12.2%) in private health institutions and 12 (2.4%) in NGO health institutions (Table 5). Two hundred nine respondents (58.1%) were willing to pay for VCT services. Of those who were willing to pay for the service, 67.5% reported that up to 10 Eth Birr is a reasonable fee, the rest said that they can pay more than 10 Eth Birr (Table 5). Concerning preference of testing methods, 219 (60.8%) preferred anonymous testing while 129(35.8%) and 12(3.3%) preferred confidential and open type of testing for HIV, respectively. Two hundred eighty seven (79.7%) of the respondents preferred face-to-face way of getting HIV test result, while 47(13.1%), 15(4.2%) and 11(3.1%) preferred secretive letter, telephone and relative/partner, respectively (Table 5). Regarding convenient time for testing, 88(24.4%) of the respondents preferred morning time from a.m, 19(5.3%) preferred afternoon p.m. and 253(70.3%) opted for any time (Table 5). 34